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Peripheral Vascular Disease Procedures

About Peripheral Vascular Disease (PVD)

What is PVD?

Peripheral vascular disease is a common circulation problem in which the arteries that carry blood to the legs or arms become narrowed or clogged. This interferes with the normal flow of blood, sometimes causing pain, but often causing no symptoms at all. The most common cause of PVD is atherosclerosis, often called "hardening of the arteries." Atherosclerosis is a gradual process in which cholesterol and scar tissue build up, forming a substance called plaque that clogs the blood vessels. In some cases, PVD may be caused by blood clots that lodge in the arteries and restrict blood flow. Left untreated, this insufficient blood flow can ultimately lead to limb amputation in some patients.

In patients suffering from atherosclerosis, the blood flow channel narrows from the buildup of plaque, preventing blood from passing through as needed and restricting the amount of oxygen and other nutrients that reaches normal tissue. The arteries also become rigid and less elastic, which hinders their ability to react to tissue demands for changes in blood flow. Many of the risk factors of atherosclerosis - high cholesterol, high blood pressure, smoking, and diabetes - may also damage the blood vessel wall, making the blood vessel prone to diffuse plaque deposits.

Symptoms

The most common symptom of PVD is called claudication, which is leg pain that occurs when walking or exercising and disappears when the person stops the activity. Other symptoms include numbness, tingling, or coldness in the lower legs and feet and ulcers or sores on the legs or feet that don't heal. Many people simply live with their pain, assuming it is a normal part of aging rather than reporting it to a doctor.

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Angiography - Minimally Invasive Surgical Solutions and Angiogram

Angiograms are performed by interventional radiologists (IR). Angiography is an X-ray exam of the arteries and veins to diagnose blockages and other blood vessel problems. During an angiogram, the doctor inserts a thin tube (catheter) into the artery through a small nick in the skin about the size of the tip of a pencil. A substance called a contrast agent (X-ray dye) is injected to make the blood vessels visible on the X-ray.  

In many cases, a IR can treat a blocked blood vessel without surgery at the same time the angiogram is performed. Interventional radiologists treat blockages with techniques called angioplasty and thrombolysis.

People with risk factors or any signs or symptoms of vascular disease, should be evaluated by a physician. Untreated vascular disease can lead to serious health problems, such as tissue death and gangrene requiring amputation or other surgery, chronic disability and pain, and weakened blood vessels that may rupture without warning. Deadly complications can result, including stroke (a clogged or narrowed blood vessel cuts the supply of blood to the brain) and pulmonary embolism (a blood clot breaks loose and travels to the heart and lungs).

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Angioplasty and Stent Placement - Minimally Invasive Surgical Solutions; Angioplasty and Stent Placement

Angioplasty is a technique used by interventional radiologists to treat blocked blood vessels. The IR inserts a very small balloon attached to a thin tube (catheter) into a blood vessel through a small nick in the skin. The catheter is threaded under X-ray guidance to the site of the blocked artery. The balloon is then inflated to open the artery.  Sometimes, a small metal scaffold tube, called a stent, is inserted to hold the blood vessel open. In many cases, interventional radiologists can open blocked or narrowed blood vessels caused by peripheral arterial disease or other
conditions. For example, in some patients, high blood pressure is caused by blockage to the artery to the kidney, a condition known as Renal Vascular Hypertension.

Interventional radiologists can often treat blocked blood vessels without surgery. In most cases, hospitalization and general anesthesia are not required.  There is no surgical incision, just a small nick in the skin and no stitches are needed. Often, patients may return to normal activity shortly after the procedure.

Between 70 percent and 90 percent of the angioplasty procedures use a stent. A stent is a hollow, thin-walled wire mesh tube which keeps the vessel open after widening it. Because arteriosclerosis, or hardening of the arteries due to a build-up of cholesterol and scar tissue, is an ongoing disease, more plaque might form and again limit blood flow. The stent is placed onto the balloon and pressed firmly against the artery wall when inflating it. The balloon then is deflated, leaving the stent in place to act as a scaffold. 

Occasionally the plaque will not remain against the inner lining of the artery but goes back to its former position after the balloon is deflated. Another possibility is that a small amount of plaque may continue to block the flow of blood. In these cases the radiologist may place a stent that is expanded at the site of plaque. 

The muscle tissue in the vessel wall holds the stent in place. In time, a layer of cells forms over the stent, which in effect becomes a part of the vessel. In some cases, the size of the diseased artery and the site of blockage make a stent especially useful.  A stent also may be placed to keep an artery open if the inflated balloon has torn or damaged it. Some modern stents are covered with a drug that helps keep the artery open; they seem to improve the long-term success rate.

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Aortic Aneurysms - Minimally Invasive Surgical Solutions and Abdominal Aortic Aneurysm (AAA)
 
An abdominal aortic aneurysm (AAA) is a weak area in the wall of the abdominal aorta, the artery that carries blood from the heart to the rest of the body. The aorta is the body's largest blood vessel. When an area is weak, it may bulge like a balloon when blood flows through it. The most common site for an aortic aneurysm to occur is below where the aorta divides to supply blood to the kidneys and above where it divides to supply blood to the pelvis and legs. An aneurysm that occurs in this location is called an abdominal aortic aneurysm (AAA).   

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Treatment of an abdominal aortic aneurysm may require surgery. For some patients, however, a new, non-surgical treatment called "stent-graft repair" can be performed by an interventional radiologist. Once an aneurysm has been diagnosed, the treatment will depend on a number of factors, such as the size of the aneurysm and the overall health of the patient. A small aneurysm may require no immediate treatment other than "watchful waiting" - checking the aneurysm regularly to be certain it does not grow. The normal diameter of the aorta is about 1 inch or less. Small aneurysms of less than 2 inches (5 centimeters) in diameter rarely rupture and may pose little risk. If an aneurysm reaches a certain size, however, there is a danger that it will burst and bleed uncontrollably (hemorrhage). In these cases treatment is necessary. If the aneurysm is small but there are symptoms, treatment may be required to prevent complications. Medication may be prescribed to lower blood pressure or to relieve pain. If the aneurysm grows to 5.5 centimeters or larger, however, physicians usually recommend treating them with surgery or with non-surgical stent-graft repair.

Stent Graft Repair

In this minimally invasive technique, an interventional radiologist uses imaging to guide a catheter and graft inside the patient's artery. For the procedure, an incision is made in the skin at the groin through which catheter is passed into the femoral artery and directed to the aortic aneurysm. Through the catheter, the physician passes a stent graft that is compressed into a small diameter within the catheter. The stent graft is advanced to the aneurysm and then opened, creating new walls in the afflicted blood vessel.

This is a less invasive method of placing a graft within the aneurysm to redirect blood flow and stop direct pressure from being exxerted on the weak aortic wall. This relatively new eliminates the need for a large abdominal incision. It also eliminates the need to clamp the aorta during the procedure, as is done in the open surgical procedure. Clamping the aorta creates significant stress on the hear, and people with severe heart disease may not be able to tolerate this major surgery. Stent grafts are most commonly considered for patients at increased surgical risk due to age or other medical conditions.

The stent graft procedure is not for everyone, though. It is still a new technology, and we don't yet have data to show that this will be a durable repair for long years. Thus, people with a life expectancy of 20 or more years may be counseled against this therapy. It is also a technology that is limited by size. The stent grafts are made in certain sizes, and the patient's anatomy must fit the graft, since grafts are not custom-built for each patient's anatomy.

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A stent-graft is threaded into the blood vessel where the aneurysm is located. The stent graft is expanded like a spring to hold tightly against the wall of the blood vessel and cut off the blood supply to the aneurysm.
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